Apply for Membership

Thank you for your interest in becoming a member of the California Podiatric Medical Association. Please complete all applicable fields and be sure to hit "submit" to have your application sent to CPMA for processing. Once processed you will be sent a pro-rated dues quote to join APMA and CPMA via email. Please provide your preferred email address to receive your dues quote to join. Please also be sure to include your home address.

For more information on Association dues, please contact the CPMA at (800) 794-8988 or e-mail at jsteed (at) calpma.org.

If you are applying for resident membership, please do not use this application. Resident members should contact APMA directly at (800) 275-2762 for membership information or use the application found here (PDF).

We look forward to working with you!

CPMA Membership Application

Fields marked with * are required.

Personal Information

First Name*

Middle Initial

Last Name*

Previous Last Name

If changed due to marriage, divorce, etc.

Sex*

Male
Female

Date of Birth*

Please enter a date, MM/DD/YYYY, e.g., 6/17/1956.

Social Security Number (Optional)

Spouse's Name

Ethnicity

For demographic use only.

White
African American
Hispanic
American Indian
Asian/Pacific
Other

US Citizen

Yes
No

Contact Information

Preferred Mailing Address*

Home
Primary Office

Home Address*

Your home address is essential for identifying and contacting your federal and state legislators.

City*

State*

Zip*

Home Phone (###) ###-####

Please include area code.

Cell Phone (###) ###-####

Please include area code.

Home Fax (###) ###-####

Please include area code.

E-Mail Address

CPMA and APMA communicate many important issues via e-mail, including membership information. Please be aware that your e-mail will NOT be shared with outside vendors.

Have you ever had a license to practice podiatric medicine suspended or revoked in any state?*

If yes, please explain in comments section below.

Yes
No

Are you currently, or have you ever been on probation, suspension or investigation by any licensure authority, state or federal agency?*

If yes, please explain in comments section below.

Yes
No

Previous member of APMA*

If yes, please explain in comments section below.

Yes
No

Dates YY-YY

Component Association

Comments

Please include any answers to the above questions that require explanation. Here you may also include the name of the member who recruited you.

Signature*

By initialing here, I understand that after submitting this application, I will be billed for Association dues. The membership process will not be completed until dues payment is received and entered by CPMA. CPMA will inform APMA and my local society of my activated membership.